Bedwetting and ADHD


(bedwetting) and Attention Deficit Hyperactivity Disorder (AD/HD or ADD)

are both common conditions that can affect children and adolescents.

Although there is no evidence that either one causes the other, children

with AD/HD appear to have a higher incidence of enuresis. The child with

AD/HD may feel different and unaccepted. Enuresis might exacerbate these

feelings. There are several medically accepted treatments for enuresis.

Some of them require impulse control and cooperation. Might this be more

difficult for individuals with AD/HD? Individuals with AD/HD may be

taking medications for the condition. How might these medications affect

their enuresis? 


all wet the bed at some point in our lives. 

When a baby’s bladder fills to a certain point, the bladder

muscles contract, and the baby urinates. Over time, the young child’s

nervous system matures. The feedback circuits between the brain and the

bladder enable the child to realize when his or her bladder is full. The

child becomes physically able to delay urination until he or she decides

that it is the appropriate time and place to void. Different children

develop the neurological and emotional capacity to control their

bladders at different ages. In many cases, children learn to control

their bladders during the day before they master nighttime dryness.

Occasional episodes of daytime or nighttime bladder accidents after five

may be a normal part of growing up. . However, if a child continues to

have regular trouble controlling his bladder after age five, he meets

the criteria for enuresis.  Bedwetting (nocturnal enuresis) usually does not occur while

the child is dreaming. It is more likely to happen during the deeper

phases of sleep.

  • Primary

    enuresis refers to wetting in a person who has never been dry for at

    least 6 months.

  • Secondary

    enuresis refers to wetting that begins after at least 6 months of


  • Nocturnal

    enuresis refers to wetting that usually occurs during sleep

    (nighttime incontinence).

  • Diurnal

    enuresis refers to wetting when awake (daytime incontinence).

How common is

bedwetting? The reported incidence varies depending on the study.

Children do not like to admit to this problem. Thus the actual incidence

may actually be higher than some estimates. 

At age five the incidence is between 5-20%. It is much more

frequent in boys than in girls. The incidence drops significantly with

age. A general rule of thumb is that about 15% of children achieve

nighttime dryness each year after age 5. 

At age 5, enuresis affects 7% of boys and 3% of girls. By age 10,

it affects 3% of boys and 2% of girls. About 1% of adolescents still

experience enuresis.  That

1% may not sound like much, but it translates into a large number of

adolescents and young adults with an

embarrassing—sometimes-humiliating—problem. What causes enuresis? We

do not know an exact cause of nighttime enuresis. 


  • Most

    children with enuresis seem to be normal, physically, intellectually

    and emotionally. Enuresis is probably associated with a combination

    of factors including heredity, slower neurological maturation, small

    bladder capacity, a tendency to produce too much urine at night, and

    the inability to recognize a full bladder while asleep. The child

    who is a deep sleeper may have more difficulty waking up when his

    bladder is full.

  • Sometimes

    enuresis may be due to anxiety, a change in the home situation (such

    as the birth of a sibling) or an emotional trauma. We particularly

    look for emotional factors in children who were previously dry and

    start to wet again. A child with shaky bladder control may be more

    likely to revert to wetting when under stress.

  • A

    small percentage of children have specific physical causes for their

    enuresis. Depending on the type of physical difficulty, the child

    might never have been dry (primary enuresis) or may have gone back

    to enuresis after a period of dryness (secondary enuresis) Physical

    problems include diabetes mellitus, lower spinal cord problems,

    congenital malformations in the genitourinary tract and urinary

    tract infections. Obstructive sleep apnea, sometimes caused when a

    child has enlarged tonsils or adenoids, can also be associated with


Treatment of

enuresis: If the enuresis is related to a specific physical or emotional

issue, the causative factor must be addressed. For the majority of

children, there is not specific cause. It is often best to counsel the

families of young children to wait and see whether the child becomes dry

within the next year or two. Parents should not be harsh or judgmental.

Sometimes it is the emotional reaction of the parent that causes the

psychological hurt, more than the bedwetting itself. The child is often

the best one to determine whether the bedwetting is a problem. Does the

bedwetting bother him? Does it interfere with sleepovers or camping

trips? The incidence of enuresis declines by about 15% per year after

age five. Bladder capacity increases, an overactive bladder may

normalize, the child learns to recognize the signal that it is time to

void, and stressful events may fade.  

However, some

children do require extra intervention for their bedwetting. Initial

interventions may include:

  • Behavior

    Modification: The child learns to take responsibility for his

    bed-wetting. Encouraging and praising the child for staying dry

    instead of punishing when the child wets. Reminding the child to

    urinate before going to bed, if he or she feels the need. Limiting

    liquid intake at least two hours before bedtime. When he wets the

    bed, he is responsible for changing the sheets in the morning. He

    learns to wake up regularly at night to void. Bedwetting alarms are

    often useful. These devices are available for $50 -$100 in specialty

    catalogs, some pharmacies and medical supply sources. A

    moisture-sensing device is attached to the pajamas or is placed

    under the sheet. When the child urinates at night, the sensor sets

    off a buzzer and or a light alarm. Some children who wet the bed are

    especially deep sleepers. In these cases, it may be necessary for

    someone else to wake the child when the alarm sounds. Ideally the

    child eventually becomes conditioned to wake up when his bladder is


  • Hypnosis:

    Some practitioners have had success using hypnosis to help

    children cooperate with behavior modification or even to become dry

    by themselves. 

  • Psychotherapy:

    This is used when the child is showing severe anxiety in relation to

    his bedwetting and this anxiety is interfering with teaching him to

    become dry. It is also useful if the enuresis is associates with

    external stress or trauma.

  • Evaluation

    for allergies: In rare cases, food or other allergies may be

    related to enuresis.

  • Medication:

    There are two main medication approaches. DDAVP (desmopressin

    acetate) is a safe and effective long-term treatment for patients

    with nocturnal enuresis. More than half of the children treated this

    way show a positive response. DDAVP is a compound similar to the

    hormone that regulates urine production. It is sprayed into the

    child’s nose at night. It decreases the production of urine for

    several hours. Children who do not respond to DDAVP may respond to a

    tricyclic antidepressant, imipramine (Brand name Tofranil.) Some

    clinicians have successfully used other, related tricyclics. These

    medications are sometimes also used for treatment of depression,

    AD/HD and narcolepsy (sleep attacks). Sometimes a parent is confused

    when their doctor suggests imipramine, “My child is not

    depressed!” For children, the FDA approves imipramine only for

    enuresis.  Tricyclics

    can sometimes be associated with changes in heart rhythm. Ask your

    doctor whether he or she feels that an EKG or other testing is

    indicated. In my experience, children who are especially deep

    sleepers, and who do not respond to other treatments, may respond

    well to the tricyclics. Unfortunately, when the medication is

    stopped, some children relapse. Some children take medication only

    when they are in special situations when bedwetting would be

    especially embarrassing—sleepovers or camping trips. Other

    children take the medication every night.


enuresis, AD/HD is also a common childhood condition. . Individuals with

inattentive ADHD have difficulty paying attention and staying organized.

Individuals with impulsive or combined ADHD have difficulty with

attention and organization but also are overly active and impulsive ADHD

affects 3-5% of school-aged children. 

Although most children with enuresis experience remission of

their enuresis by age 18, a higher percentage of individuals with AD/HD

continue to experience inattention and impulsivity well into adulthood.

For years, clinicians have anecdotally noted an increased incidence of

enuresis in children with AD/HD.  Others

have observed that their patients with enuresis have an increased

incidence of AD/HD. Because both conditions are fairly common, it would

be important to have more systematic studies that looked at the

relationship between enuresis and AD/HD.


article in the Southern Medical Journal published in 1997compared a

fairly large group of 6-year-old children with AD/HD to a non-AD/HD

control group selected from a pediatric clinic population. 

They found that the 6-year-olds with AD/HD had 2.7 times higher

incidence of enuresis and a 4.5 times higher incidence of diurnal

(daytime) enuresis as compared to a control group Other authors have

cited higher rates of enuresis in children with ADHD. However, these

studies did not have control groups or were not selected randomly.


enuresis may be more upsetting for a child with AD/HD. 

A non-AD/HD child, who is successful in most spheres, may be able

to accept his bedwetting more easily. Later, such a child may find it

easier to cooperate with behavioral interventions. However the child

with ADHD already feels different from his peers. His disorganization

and impulsivity may lead to peer rejection and shame. Such a child may

cover his shame with a false appearance of bravado. And although he may

be more ashamed of his bedwetting, his inattention and disorganization

may make it more difficult for him to cooperate with some behavioral

treatments. Individuals with AD/HD are more likely to have sleep

problems. Some of them sleep deeply and have difficulty waking up to go

to the bathroom when their bladder is full.


the child with both AD/HD and enuresis: This child should have a

complete physical exam. It is important to always ask an individual with

AD/HD about current and past bedwetting problems. Don’t neglect to ask

adolescents about this too. They will rarely volunteer this information

on their own. Ask what they and their parents have tried in the past.

Some children and teens with AD/HD are veterans of many types of

therapy. They may already expect the treatment to fail. The behavioral

techniques listed earlier in the article are still useful for these

children and teens. Since these children have often experienced teasing

and criticism, one should be especially careful to avoid punitive

behavioral techniques. One may have to modify behavioral interventions

to accommodate the child’s shorter attention span. You may need to

prioritize symptoms. If the child has a myriad of behavior difficulties,

the family cannot address all of them at once. Which ones are the most

important to the child and the parent? Some children and families opt to

wait a while longer before starting behavioral or medical interventions. 

When  the family

decides that this is the time to treat the enuresis, they may have to

back off with some of their other behavioral goals to avoid being

overwhelmed. The child and family should be made aware that there are

several ways to treat the enuresis. If one does not work, you are not a

failure. You still have plan B, plan C, etc.


for children with both AD/HD and enuresis. Some children with AD/HD

may also have other psychiatric disorders and may be on several

medications. A few of these medications might exacerbate the enuresis. 

It is important to consider all medications and all medical

conditions before proceeding with treatment.  

DDAVP help the enuresis of some children and teens with AD/HD..

In other cases, one may want to consider one of the tricyclic

antidepressants for the enuresis. This class of medication seems to work

well with some of the “deep sleeper” kids.. You may be able to treat

both the AD/HD and the enuresis with one medication. Several studies

have shown that the tricyclics by themselves are an effective medical

treatment for AD/HD in children and adults 

In some cases, one can combine stimulants and tricyclics. Such

cases may require more frequent medical monitoring.


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